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24C-106 (3) 107 MASSASOIT ST BP-2019-1037 GIs 4: COMMONWEALTH OF MASSACHUSETTS Map:Block:24C- 106 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category,woodstove BUILDING PERMIT Permit# BP-2019-1037 Proiect9 JS-2019-001694 Est.Cost,.$2900.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO. Const.Class: Contractor: License: Use Group: TRI STATE CHIMNEY SWEEP 098862 Lot Size(w.it): 12109.68 Owner, KROGIUS TOR A W&SARA HALPER Zoning:URB(I00 Annikant: TRI STATE CHIMNEY SWEEP AT. 107 MASSASOIT ST AnalicantAddress: Phone: Insurance. 33 PARKER ST (800) 530-6639 WINCHESTERNHO3470 ISSUED ON:3/2I/20I9 0:00:00 TO PERFORM THE FOLLOWING WORIGWOODSTOVE - REGENCY POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House p Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department FimplaWChimaey: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Showmen: FeeTvpe: Date Paid: Amount: Building 3/21/20190:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner City of Northampton Massachusetts NED D5PARl w OF aUILDIMU IMSP=ZONS S 212 Main Street • M LciP l ecilding aort4arytan, MA 01060 .tel+a-' A 2 0 2019 15P- 6-1037 -2Yc ' <6Ce DF NO `T AMPTON'Mkolmclpl: SINGLE OR TWO FAMILY SOLID FUEL APPLIANCE PERMIT'APPLICATION FOR WOOD,COAL,PELLET,CORN,STRAWOR8� (M` OR FIREPLACES CheatMR5( ©1 Plesse fl0 in aN approprlats Information 1. Name of Applicant: Tf 1 SV6VC CAmtv r1[j LLC- Address. l.Q`I MQSSQCl1\'t S1tnn_W39 2. Ownerof Pmpedy: 70r krosIwS Address: lo7 NCLSSQSO\r S}�Noyt� arxV}z+y+Tdephone: V 13 (AS-3'17S 3. Status of Applicart:_Owrter ✓ Cor6araor ,L Type or Brand ofStove:'P—eC,' ICq ` �WVQ' Ci (ZAP S. LILListing:OL3d6 JLC 2aa61>)IC 562 as 6. Estimated Cost\i2" � t a V T Email: pQ\J\ @ I S:-`r-Me C N CO rY1 R applicant Is not the homeoam er:: Contractor name WC :�,� l�,. N'OA O AO F� Email: yrs . l•.OM Construction Supervisors License Number CSSL'0aW(' 2 Expiration Data ka Home Improvement Contractor Registration Number 177 Sbc7 Expiration Dant 1 20ZO All Applicants must complete a Workers Compensation Insurance Affidavit ee/ore we can issue a permM 6. Certrfication: I nearby certify that the information contained herein is true and accurate to the best of my knowledge. DATE:--2 Q 11 19 APPLICANT'S SIGNATURE ""^ ✓" Ltzi DATE: 411 HOMEOWNER'S SIGNATURE APPROVED DATE: 3.20-2619 BUILDING OFFICIAL h 4 The Cornmonweatrh ofMassachusem Department of IndusarialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www brurixgov/dto Wiliarlivers'Compenhadion Insurance ARrdavB:BuBders/Contractors/Elerhiciaos/Plumben. TO BE FILED WITH THE PERMITTING AUTHORTIV. Aorlicant Information Phrase Print Legibly Name(BwimsVCkge,drslion/indmidual): TC; StaVC G jv-F,^eu SWeee!pc LL-(_ Address: 33 ?ark-et' Sfi City/StaWZip:WincheskcL NI4 03470 Phone#: i06S36- t.1639 Acer..an O.W.Chick d ."P pme ba: Type ofproject(regdred): I.®Iaria mwloya with--I—enmlovees(fult vid"w paa-berate 7. ❑New construction 2�Iwn a.+ok pmpdamorpaMernhipaM haveroertgkyees wmkiry frroem g, ❑Remodeling m wwuitr.INo aorta:'antro immmre reauiteal 3.Olamelwntmwmrdoittgdl work trryxlf.INo workaa'axnPinswwee reauitm.lt 9. QDOmOlilion 4.[:]1 am a hamowmrtud will ha hiring wnaadwa m emdwa ell work on my PmttM- I will 10❑Building addition aurae thus W]mmuct.either haswMers'catmeremior mou.mere sole I LE]EIectricld repairs or additions "wirtors with ria emplayas 12.[]Plumbing repairs or additions 5c]1rana ,ocrol comae wo l have hire the wbe ucs rsa on aemlane shin. nI3.�Raofrepairs esesuhcomrecton hate cmPloy'.�aM lave wahers'mmp. mmwee.t � � `_ ` JCA b.�We areacmgtmlon aM ns oRaers have ccertisW tMir right MemmPlion per MGLc 14.®Other 1.vC 'n j- ge 152,§I(41radisehurennemplmeo.INownAersamti.immameterlubsil C} \Y)0.4�A'1-IOYI -Am alplicaut eMeks hus 4 I must id-fill out the action below showing their wufken'cort,matmo Or,mfomatian. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mun submit a now,amdwit it ifica tg such, m.so,that check this box must mmched an usibl owl Acc,slmwing the name of the subcunttactors aM sae.Mahar or and those entities have cmpl-ccs Ifthe subusmmwrs have employee;t4-muvt pnwiJctMir wodets'ramp.polity number. f am an employer that is providing workers'compensation Lowe m for my employees. Below is the policy andjob site informaaon. \ _ Insurance Company Name: )RSIO`ll tl. C—Vd -Cf JY\S\,kfa"ck G1-0\AV Policy 11 or Self-ins.Lic.4: W C 4 O I O9 3)1 0 C; Expiration Date: 7I2SM Job Site Address: 107 YVDSSClS0\V S�- City/StatelZip:NOYdInO.M��O✓s ) I'yj\t} 01060 Attach a copy of the workers'eompeaaation policy declaration page phowiag the policy nomber and expiration date). Failure to secure coverage as required under MGI.c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may he forwarded to the Office of Investigations of the DIA for insurance coverage verificalion. Ido herebye Mn a pains andprna ofperjury thar/he informationprovided above is true andeorrea Si mature s)(-))g Ph,,,ea: TSM S3 - 1063 OJrrial use only. Do nm write inthis arca,m he completed by em,or nswn nJfoial. ('ity or Town: Permit'License d Issuing Authority(circle one): I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone a: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant W this m m e.an employee is defined as-...every person in the service of another under any contract of hire, express or implied oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or mote of the foregoing engaged in ajoinn enterprise,and including the legal representatives of a deceased employer,or the receiveror trustee of m individual,partnership,association m other legal entity,employing employees. However the ownerof a dwelling house having not more than three apartments and who rt' idm therein,or the occupant ofthe dwelling house of another who employs persons W do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MUL chapter 152,§25C(6)also states that"every stale or local licensing agency shall withhold the issuance or renewal ofa license or permit W operate a bmium or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth am arty of its political subdivisiorm shall enter into any contract for the performance ofpublic work until acceptable evidence of-compliance with the insurance requirements ol'this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and if necessary,supply subcontractor(s)name(s),addresses)and phone commons)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners are m required to carry workers compmmation insurance. If m LLC m LLP does have employees,a policy is required Be advised than this affidavit may be submitted m the Deportment of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and data the a/RdaviL The affidavit should be returned W the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or ifyou are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sum that the affidavit is complete and printed legibly. "Dere Deportment has provided a space al the bottom ofthe affidavit for you ta fill out in the event the Office of Investigations has W contact you regarding the applicaaL Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant then must submit multiple permh/license applications in any given year,need only submit one affidavit indicating current policy information(ifnecessary)and under"Job Site Address"the applicant should write"dl locations in_(city or town)."A copy ofthe affidavit that has been officially stumped or marked by the city or Wwn may be provided to the applicant as proofdmt a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.wheat a home owner or titian is obtaining a license or permit not related W any business or commercial venture (i.e.a dog license or permit to bum leaves ale.)said person is NOT required to complete this affidavit- The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 Tel.#617-7274900 ext. 7406 or 1-877-MASSAFE Fax Al 617-727-7749 Revised 02-23-15 www.mass.gov/dia .ACl ld CERTIFICATE OF LIABILITY INSURANCE Ofl?P 2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED 13Y THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: H t N,cartlBlxls holder Is an ADDITIONAL INSURED, the poll y(IBD) mail be endorsed. N SUBROGATION IS WAIVED,subject 0 the toms,Mid conditions o1 the policy,car, In policies may require an endorcenlent A 9U3Mtlent on this certificate does rot confer right to th ufd6Eete holder N IMu of such PRODUCER NAW Cheryl Selair THE INSURANCE SOURCE INC °NdMem�- Bos 3573219 FA, MnLAMM: rsllusorl82COURTST u1VrmFlgcoYwli e KEENE NH 03x31CHAR3ER INS 00 44828 IX m TRI STATE CHIMNEY SWEEPE LLC 33 PARKER STREET WINCHESTER NH 03470 COVERAGES CERTIFICATE NUMBER: 3OW62 REVISION NUMBEID THIS IB TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO VMICH THIS CERDFIGTE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SIBIECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.UNITS SHONa1 MAY HAVE BEEN REDUCED BY PAID CLAIM. _ IYM OFWRIMNp{ IF rMUMeeN O1 Ym a1s�MOtLaMBMLMAMDY 'FACHOCcuRRHYlf s mAMNarADE ❑OCCUR { 3�D ExP Nti r+ $ WA PEa90NK&AP I JURY` { �ILA00YMlEp�gWINQ}TAPft19PBt gEr1EFPL AGGREGATE { PmLY�1ST ❑IDD PR M-WMPWT e AIR0r0�aMYMlli I s ANyiplp BDDLLYeaUtf( rpee{ i AUTO@ WA aapLr NAm-IP'rsWe9 s 111r®AaTOe AUOM { { glMl®IAMNOCCUR Fi1CxtICCIMRBICE { eisLMs UAMNMDE WA AGGREMAE { sucluxas i IIDleOlMCa1MMMAlM AMBEIq'El llAialR Yin AryP iM�IffeFxcumEm 59 M M11 WCV01093105 OT!l 018 DTRB/=9 s 1 00.0111111 o aCai'rvn.or" toxo aw ELOMEAeE-PaA:rusr s aw.000 N/A ooersras oroFBMTTorMllaumaslvFAears y1WRD tm.AaamwR...em,ww.,mnietr.++re.,w.y..rr�.ri Yhorkes'Compensation bereft will be paid to Massachuset s employees only.Pursuant to Endolserne rt VYC 20 03 OS B,no euthorireeon is given to pay claims for bereft to employees in states other shot Massachusetts 0the insured him,or has hired does employees outside of Massachusetts This certficate of Insurance shows the policy In force on the date that this cemficate was issued(unless the awiraeon date on the above policy precedes Bre issue date of this mN8®te of Insurance). The staalsof this coverage can be monitored daily by accessing the Proof of Coverage-Coverage VsrwhoaHon Search foal at www.mass.gwRwdNiorkarammpenaeaorWreetipstlone/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES SE CANCELED 9E 11E THE EXPIRATION DAM THEREOF, NOTICE Will BE DELIVERED IN ACCORDANCE WITH WE POLICY PROVISION& ADRpI®R91aBF1RATIYE ORW M.Crwylsy,CPCU,Vice President-Residual Markel-VACRIBMA 01988-2014 ACORD CORPORATION. All dgNb reserved. ACORD 25(2014AT7) The ACORD nems and logo am registered marks of ACORD Lp �II w3 d 9 r .. �'MOW ---------------------------------- - -=-- -------------- --- 387 ITAsMIL(Yr n F---------------------------------------------- -------------- �N CoA» CAUTION [L[INCEWW ATTENTION: HNNIt LLCMLLW ILLIEtl.iWILLG YfiM CM[IYY M RMLMC Y�pILY 1NYW VKiWLf IIC]YIAICMLM W9(LINOINtT1°CIIM.IWTLLLY[)YNOILY M[YNOMtINTWnINL[pPREPUCE OR[FACTORY SORT SCS RTSA4 OiLOCLLWLpXOMIILCICA41YWC. fYWNC t LYYMN' LLINVEIxY °L L E1J1 A.. Ux1.1.1. APFEY[VO]REW ICIENOLMYEKW [UMMNDIMUxNELIXALIWRLUCMESO!W1YXgiTC1Rl WwCN I NtT...IT I.I.Pt Qgo') M�CIEMNIC[STOCOMWMLEY1M1°LL. 4l°RmfRd URIBYRSS', xrtuL My M n MxcoMeueneLe IEMM 0.ANEn RI I NNS YLR [WVEEJI LOMCIR CW&M1CLE flOOR.[ U.'tE PROTECTED BY NO MMSTKKE NNTERVUI ARTEMONO1O° HOT WMLE M OK RATION tlISCBT...AI Y.,NY. 1 HIi$lNiSURS. SUR.I.N�IS]E NIIO FfOMAR.I.,.1.1 YW �xOl N-.7104.1gICN. NEEAL.LOREN. "A'" LII�I N IIw CLOTIO Ah.1.ITURE SIWY. 1CINCNO C ISIRA 1 ... It WRUY111n..SAYMNCOWV.YRUS MWW BOE FCNO OI].SPUR I I:— ; MILL.....LCMILEtWt Wf1AMLNERCOYWtIII[SDJSC[Yl. CONTACT WY CWSES NM.."SUS PYNCNw CIBRB. US W ROM.PROTEGE PAR LL SUL"..m RG ABOVE INSMMTKINL CMWTSY WI SMNML I....A, FYY PTATWML I\N IM]AM IbxI EYAVAYTtY MI I IN AUO LOSS OR I'DNRONUMMUIT SUR I[{CO=OL US POSTS. R LIEN, ...Y" nEiuutAL �COwMMPLRWIlO IM YTWAI[IY:If INrNMR' NR WI RANYSSR[6l1MLE140NC AGVig111fIAY1MMUl LW. YV101111]IRNL RAOSIC COIMtl1SNI 6lCTM' IWNO:WLn 11LY1[. COMiACI AYEC LE IE/.V IEVi OC. WL° ME D�CTLIOI MMTN.WRISTS THFEED`DOOR CLLdED,AM IO PEM TRIP LILY RUAIl WRJIOILYNDN ULORLYIMY [�OgxfNDIIVIYfUEl1ROLYb COAIE{NINA NYNTIMD CLIP CNYKYIRLW LNILY. MNEL UR.Vx CO1OTCNS OFVY[RW[OTI WLWP WY WCYIIONOLY. LIIN CPRE ETDYETR. DONOIMSLFRE.II WwT WOY[YW NN OMN}Mq. fIlA1M �rSScu nnREAISSL POUR IS .. Afr ll..M 11.1 I R NMYM�u.MArtAn..OR CM"O ORBY 1 FIMS(RANULOT11.OY C"DE 11]{43.1 COSMOMNT ITAxDRAID P nRL RRRU —PLRR BROUS"l ROSS. US NELLeveRNwIWM RINMN[ROU FOYER LORROM POUR OlIC7.L nuTALI-A IND{OUIOI'S EROALTRABUILVTILL=RRUL[NRR "ROS DI UAMIROL SIR PAR VYMSS.UP.MILLE.ETASMUS F EU OPECMNENT SUR LEHRIWESDAMLEFOMOUPULL.OPNR2 RLAr .1. �CLAAORTSORCRULABOUIISNYINWPC UZ.TNMOY![O.LYOM[CREWNSEEPOUR RFIREWFIYYENL YLFR[W[MUO'VTILILATIOx BY LATLNMMTYREAM WELRRPMLIATVMNEDIMCMROLLILREFEVTAFFERERCERL.ICCVNYLATICNUCMOEOTE.XE PA,:: 1 fw. 5[Mlb.'Ib MEMT1 OATS OR H11 U's .11 HH H31 1. FEB YM AM WY JOBS JUN. WO ER OCT MOV OCC NAMORA.YU.1 O O O O O ❑ ❑ ❑ ❑ ❑ ❑ El ❑ ❑ ❑ ❑ 1367